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ISSN: 0959-3985 (print), 1532-5040 (electronic)
Physiother Theory Pract, 2014; 30(2): 138148
! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2013.819952
CASE REPORTSERIES
Physical Therapy Program, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USA and 2St. Josephs Hospital and Medical Center,
Barrow Neurological Institute, Phoenix, AZ, USA
Abstract
Keywords
The purpose of this case series is to describe changes in impairments and activity limitations in
three individuals with severe cerebellar ataxia from traumatic brain injury (TBI) who participated
in a long-term, multidimensional physical therapy program. A secondary purpose is to
document use of a climbing wall for these persons. Each of the individuals had a TBI, severe
ataxia and was admitted to a transitional neuro-rehabilitation day treatment program. The first
person, a 22-year-old, was 6 years post injury and had 127 individual physical therapy sessions
over 12 months. The second person, a 16-year-old, was 5 months post injury and had 187
individual therapy sessions over 19 months. The third person, a 20-year-old, was 6 months post
injury and had 89 individual therapy sessions over 23 months. An integrative treatment
approach was used, and the individuals participated in activities to minimize ataxia and
improve mobility. Each of them made gains in coordination, balance, balance confidence,
endurance and mobility. The three individuals with cerebellar ataxia participated in a long-term,
individualized, multidimensional physical therapy treatment program, and made improvements
in all areas of impairment and activity limitations. This study reinforces the need for long-term,
multidimensional physical therapy for individuals with ataxia.
20
14
Introduction
History
DOI: 10.3109/09593985.2013.819952
Methods
Following TBI and prior courses of rehabilitation, the individuals
in this report were admitted to an out-patient, day rehabilitation
program for adolescents and adults with brain injury to enable
them to gain home independence, work reentry and/or school
reentry. Each of the individuals received neuropsychology
services, recreation therapy, speech and language therapy, physical therapy, occupational therapy and dietician consultation.
Two of the individuals, KS and AL, also received vocational
counseling. Therapy was provided in individual treatment
sessions and in group or milieu sessions. People admitted to the
out-patient, day rehabilitation program were seen by all or most
disciplines 4 to 5 days per week in the beginning and middle of
their course of rehabilitation. As goals were achieved and
integration into work or school settings occurred, therapies were
gradually discontinued with neuropsychology often the last
service to be discontinued.
Description of tests and measures
Tests and measures standard to the facility were conducted at
admission, monthly and at discharge. Selection of the set of tests
and measures had occurred over years of working with individuals
with TBI, utilizing the clinical expertise of the therapists and the
evidence from the literature supporting these tests. Tests of
somatosensation (light touch, proprioception and sharp/dull
sensation) (Schmitz, 2007b); tone (resistance to passive stretch
and presence/absence of ankle clonus) (OSullivan, 2007c); and
strength (manual muscle test of back extensors and abdominals
and major muscle groups of hip, knee and ankle with 05 scale)
were conducted (Kendall, Kendall, and Wadsworth, 1971). Two
tests were used to examine coordination of the lower extremities:
(1) the number of seconds to complete 10 heel-to-shin movements
(average of three trials); and (2) the number of toe taps completed
in 10 s (average of three trials) (Schmitz, 2007a). The ability to
smoothly perform at least three heel-to-shin movements is part of
the Brief Ataxia Rating Scale (Cronbachs alpha 0.90)
(Schmahmann, Gardner, MacMore, and Vangel, 2009). The
number of toe taps completed in 10 s has been used to measure
voluntary muscle activation in healthy young and older adults
(47 1 taps/10 s and 34 1 taps/10 s, respectively) (Kent-Braun
and Ng, 1999). Individuals with cerebellar injury have increased
variability in rhythmic tapping of the foot ipsilateral to the lesion
in comparison to the contralateral foot (Ivry, Keele, and Diener,
1988).
The Berg Balance Scale (BBS), one leg stance time (OLST),
stand on one leg eyes closed (SOLEC) and the NeuroCom
Sensory Organization Test (SOT) were used to measure balance.
The BBS (Berg, Wood-Dauphinee, Williams, and Maki, 1992) is
comprised of 14 different tasks graded on a 56-point scale
(Feld, Rabadi, Blau, and Jordan, 2001). The BBS has good testretest reliability (ICC 0.986) for individuals with TBI
139
140
Coordination of
extremity movement
Balance
DOI: 10.3109/09593985.2013.819952
Case descriptions
1 (KS)
Case 1
History
KS was a 22-year-old female, admitted 6 years following a motor
vehicle accident. Initial results of neurodiagnostic imaging
showed multiple skull fractures, traumatic subarachnoid hemorrhage, external injury of cerebellum and frontal lobes, diffuse
axonal injury, multifocal shear injuries, mild subdural hematoma,
cerebellar hemorrhages and punctate hemorrhages in the mesencephalon. Initial Glasgow Coma Scale (GCS) rating was 3. She
also had a fracture of the left (L) clavicle. One year later
electroencephalography showed abnormal slowing in the posterior
temporal regions bilaterally, especially on the right (R). Course of
therapy prior to admission to the out-patient, day-long treatment
program consisted of 4 weeks of acute care, 8 weeks of sub-acute
rehabilitation, 5 weeks of in-patient acute rehabilitation and
approximately 3 years of intermittent out-patient therapy. Status at
the time of discharge from acute rehabilitation was minimal
assistance for bed mobility, minimal to moderate assistance for
level transfers, moderate assistance for sit to stand and ambulation
with a bilateral platform front-wheeled walker (FWW) with
minimal assistance of one to two persons. Prior to the injury, she
was described as very sociable and participated in biking,
rollerblading and babysitting. At the time of admission she was
living at home with her family and enjoyed shopping, talking on
the phone, watching television, listening to music, visiting with
friends and going out to eat and to the movies. Although she had a
wheelchair and assistive devices for walking at home, her primary
means of mobility was walking while holding onto to her mother
for support. She was admitted to the work reentry program and her
stated goals were to live independently, to go out more in the
community and to enjoy herself.
Examination
Initial examination of KS revealed intact lower extremity (LE)
somatosensation. LE strength was 4/5 to 5/5. Abdominal and back
extensor strength were both 4/5. She had severe LE ataxia,
with slow and dysmetric heel-to-shin and toe taps: R toe
taps (19.0 repetitions/10 s); L toe taps (2.4 repetitions/10 s);
R heel-to-shin (10 repetitions/14.8 s); and L heel-to-shin
(10 repetitions/17.2 s). She scored 26/56 on the BBS and 91/100
on the FES (Table 2). OLST was 2 s bilaterally; she could
not perform SOLEC. She was modified independent in wheelchair mobility and required stand-by assistance for wheelchair
and toilet transfers. She ambulated with a FWW with contact
guard assistance for short distances. She walked 171 meters on the
6MWT with maximum assistance without an assistive device.
The 6MWT was conducted without an assistive device as she had
a history of not using an assistive device at home. Gait deviations
were LE scissoring and loss of balance a minimum of 15 times.
Neuropsychological testing revealed impairments in executive
cognitive functioning. Three months after admission she was
tested using the SOT, receiving a composite score of 40%.
Evaluation and prognosis
The examination revealed severe cerebellar ataxia with impairments in coordination, balance and gait and KS required
assistance for transfers and walking. Her low GCS rating
(Foreman et al, 2007; Ono et al, 2001) and long time since
injury were factors that could potentially affect her potential for
141
2 (EB)
3 (AL)
Measure
Initial
Discharge
Change
26
91
43
94
17a
3
2.0
2.0
40
171
4
37
2.9
2.7
47
247
23
95
0.9
0.7
7
76b
19a
58
0
0
NT
61
34
72
3.5
1.5
NT
259
51
97
3.5
1.5
6.3
3.7
62
282
20.0
6.6
73
549
13.7
2.9
11
267b
198b
17a
25
142
Table 3. Individual therapy session interventions and aims for case 1 (KS).
Interventions
Aims
Trunk strengthening
Therapy ball exercises
Exercise in quadruped
Gait training with reciprocal poles (weighted and un-weighted), front-wheeled walker, forearm
crutches, four-wheeled walker, without assistive device; various surfaces; in community
Neurodevelopmental treatment
Proprioceptive neuromuscular facilitation using wrist and ankle weights or pulleys while
in standing
Carrying objects while walking with and without walker
Transfer training
Resisted gait
Standing weight shifting; walking in various directions while stabilizing against a wall;
walking at various speeds; walking in all directions with weighted extremities,
walking eyes open and closed
Listed interventions are from daily notes and monthly reports in the persons medical record.
the course of treatment and her time walking with the walker
increased from using it in the afternoons at the out-patient, daylong treatment program and as often as possible at home to using
a four-wheeled walker as her sole means of mobility.
Outcome
At discharge, LE strength was 4/5 to 5/5. Abdominal and back
extensor strength were both 4/5. She had moderate LE ataxia:
R toe taps (25 repetitions/10 s); L toe taps (24 repetitions/10 s);
R heel-to-shin (10 repetitions/7.3 s); and L heel-to-shin
(10 repetitions/7.2 s). She scored 43/56 on the BBS (17-point
change) and 94/100 on the FES (3-point change) (Table 2). OLST
was 2.9 s on the RLE and 2.7 s on the LLE; KS could not perform
SOLEC. She received a composite score of 47% on the SOT
(7-point change). She was modified independent with transfers.
She ambulated with a four-wheeled walker with modified
independence indoors and supervision outdoors. She walked
247 meters on the 6MWT with a four-wheeled walker (76-meter
change); gait observation revealed minimal veering from the path,
no loss of balance or toe dragging, minimal to moderate ataxia
with good stride length and base of support and no scissoring.
At discharge, KS continued to live with family and was working
part-time. She was instructed to continue strengthening and
cardiovascular exercise 3 to 5 d per week.
Case 2
History
EB was a 16-year-old male, admitted to the out-patient, day-long
treatment program 5 months after an auto-pedestrian accident.
Initial GCS rating and results of initial neurodiagnostic imaging
were not included in his admission record to the out-patient, daylong treatment program. Immediately after the injury he underwent an L craniotomy for evacuation of a frontaltemporal epidural
hematoma. Other injuries included an L clavicular fracture and L
temporal skull fracture. He had respiratory failure, requiring a
tracheostomy, and he developed pseudomonas pneumonia.
Neurodiagnostic imaging 15 weeks after injury revealed innumerable foci throughout the deep white matter of bilateral
cerebellar hemispheres and cerebral hemispheres consistent with
diffuse axonal injury. Course of therapy prior to admission to the
out-patient, day-long treatment program consisted of 2 weeks of
acute care, 10 weeks of sub-acute rehabilitation and 9 weeks of
in-patient acute rehabilitation. During the course of acute
rehabilitation, EB was discharged to acute care for a repair of a
tracheocutaneous fistula, and was then re-admitted to the acute
DOI: 10.3109/09593985.2013.819952
143
Table 4. Individual therapy session interventions and aims for case 2 (EB).
Interventions
Aims
a
First admission.
Second admission.
Listed interventions are from daily notes and monthly reports in the persons medical record.
Independence in mobility
Balance, independence in mobility
Proximal stability, coordination, balance
Proximal stability, back extensor strength
Proximal stability coordination, strength
Coordination, gait, independence in mobility
Proximal stability
Balance
Coordination, balance
Balance, gait
Coordination
Lower extremity strength
144
Intervention
AL was at the out-patient, day-long treatment program for
24 months and received physical therapy for 23 months. Initially
he received physical therapy 4 to 5 d per week, decreasing to 1 to
2 d per week. He received 89 individual physical therapy sessions,
26 balance group sessions, 54 motor group sessions, 3 pool
therapy sessions and 1 session of rock climbing. The physical
therapist also attended a work-trial session and three city bus
training sessions, and made three visits to his fitness facility.
Physical therapy interventions conducted during individual therapy sessions are listed in Table 5. Multitasking was incorporated
into physical therapy sessions to improve his ability to perform
dual tasks so that he could ambulate safely at school and work.
A backpack was utilized to weight the trunk for stability and was
also functional for return to school. During the course of
intervention, a leg length discrepancy (3/4 inch) became evident
during gait observation. Further examination, including performance of a Thomas Test (Dutton, 2012), by the physical therapist
and an orthotist determined that the discrepancy was likely from
shortening of connective tissue at the hip due to the individual
walking in a more flexed posture to compensate for proximal
instability. The physical therapist prescribed shoe modification for
the leg length discrepancy, allowing for improved biomechanical
alignment. Group balance interventions included Tai Chi, singleleg stance and other balance activities. Motor group sessions
consisted of exercise on the Airdyne bike, treadmill walking and
stationary bicycle exercise. He participated in one session of rock
climbing approximately 9 months after his admission, climbing
three walls during the session.
He was instructed and advanced in a daily HEP including
simple flexibility, coordination and strengthening exercises
modified over the course of treatment. He documented his
adherence to the program with a home independence checklist.
Over the admission, his use of the FWW was discontinued, and he
progressed to walking without the walker, but wearing a backpack
for stability. He eventually walked without a backpack.
Outcome
At discharge, LE strength was 4/5 to 5/5. Abdominal and back
extensor strength were both 5/5. He had mild ankle clonus. Heelto-shin and toe taps were performed smoothly: R toe taps
(39 repetitions/10 s); L toe taps (24 repetitions/10 s); R heelto-shin (10 repetitions/7.1 s); and L heel-to-shin (10 repetitions/
7.3 s). He scored 51/56 on the BBS (17-point change) and 97/100
on the FES (25-point change) (Table 2). OLST was 20 s on the
RLE, 6.6 s on the LLE; SOLEC on the RLE was 3.7 s and he
Table 5. Individual therapy session interventions and aims for case 3 (AL).
Interventions
Therapy ball exercises
Gait training with reciprocal poles, weighted walker, front-wheeled walker, bilateral
straight canes, without device; varying surfaces; in community
Proprioceptive neuromuscular facilitation with wrist and ankle weights or pulleys in
standing
Balance beam activities with and without multitasking
Tandem gait; braiding; toe walking; jumping jacks; jumping and hopping activities
Resisted gait
High level balance activities using weight shifting, increasing speed of movement,
changing direction of movement; walking with head turns
Stair climbing without handrail and at increasing speeds; curb and obstacle negotiation
Exercise to exercise video; jogging on floor, treadmill
Donning and doffing backpack, walking with backpack
Listed interventions are from daily notes and monthly reports in the persons medical record.
Aims
Proximal stability, coordination, balance
Coordination, gait, independence in mobility
Balance, strength
Balance, dual tasks
Coordination, balance, gait
Proximal stability, gait
Balance
Coordination, balance, independence in mobility
Coordination, balance, speed, dual tasks
Proximal stability, participation in school
DOI: 10.3109/09593985.2013.819952
Discussion
The individuals in this case series with cerebellar ataxia due to
TBI demonstrated improvements in body functions (impairments), activities and participation following involvement in a
long-term, multidimensional physical therapy intervention program. The multidimensional program was customized for the
severity of each persons impairments and activity limitations,
and incorporated the persons goals and lifestyle. The program
contained traditional interventions for ataxia, such as work
in quadruped (OSullivan, 2007b), but also included: strengthening and endurance activities; balance activities incorporating
sitting, standing and walking under various environmental
conditions; Tai Chi; multitasking; pool therapy; rock climbing;
and task-specific practice of ambulation in the clinic, home and
community to improve learning and carryover. The physical
therapist visited the individuals prospective workplace, school
and fitness facility.
Recommendations for treatment of ataxia often come from the
literature on ataxia related to diagnoses other than TBI such as
cerebellar degeneration (Ilg et al, 2009; Sliwa, Thatcher, and Jet,
1994); Charcot-Marie-Tooth disease (Vinci, 2003) or multiple
sclerosis (Armutlu, Karabudak, and Nurlu, 2001; OSullivan,
2007a). Similar to this study, Armutlu, Karabudak, and Nurlu
(2001) used a multidimensional treatment approach for ataxic
multiple sclerosis. Examples of interventions included in that
study were Frenkels exercises, proprioceptive neuromuscular
facilitation, balance training, Cawthorne-Cooksey exercises,
pressure splints and ambulation on various surfaces, and the
authors concluded that a combination of suitable techniques
should be used, particularly for the more resistant symptoms
(Armutlu, Karabudak, and Nurlu, 2001). For individuals with
cerebellar degeneration, Ilg et al (2009) used a program of
balance exercises, whole body movements and strategies and
training to prevent falling.
The individuals in this case series received therapy over a long
period of time. Longer duration and increased intensity of training
have been recommended for individuals with cerebellar ataxia in
previous studies (Cernak, Stevens, Price, and Shumway-Cook,
2008; Dordel, 1987; Morton and Bastian, 2004). Duration of
programs vary from: 4 weeks (Ilg et al, 2009; Vaz et al, 2008);
6 weeks (Gill-Body, Popat, Parker, and Krebs, 1997); and
7 months (Dordel, 1987). However, Dordel (1987) remarked
that therapy is often discontinued too soon. For instance, Balliet,
Harbst, Kim, and Stewart (1987) reported improvements in one
patient 10 years post TBI after 2 years of therapy.
All of the individuals BBS scores at discharge exceeded the
4-point MDC95 for individuals with TBI (Newstead, Hinman, and
Tomberlin, 2005; Steffen and Seney, 2008); 17 points, 19 points
and 17 points for KS, EB and AL, respectively. All of individuals
change in 6MWT distances surpassed the 13% relative improvement (SRD%) (Flansbjer et al, 2005) needed to indicate a real
clinical improvement for individuals with stroke. KS walked
76 meters further at discharge (22 meters were needed to exceed
13%); EB walked 198 meters further at discharge (8 meters were
needed); and AL walked 267 meters further (37 meters were
145
146
Limitations
This case series report has several limitations including use of
retrospective data and inclusion of individuals of one age
group. There was inconsistency in time since onset from injury
to time of admission. Future research on interventions for
cerebellar ataxia due to TBI should include persons with TBI
of all age groups and receiving longer-term interventions.
This case series did not outline a specific therapy regime for
ataxia or document the effectiveness of one particular intervention
for ataxia, both of which are thought to be missing from
the literature (Martin, Tan, Bragge, and Bialocerkowski, 2009).
The study did not include a measure of quality of life. The
persons in this case series only participated in one session of rock
climbing. Although they climbed two to three times during
that session, future research needs to include more bouts of
climbing and quantitative data collection. Despite these limitations, the similarity in age and severity of impairments and
activity limitations, the standardized outcome measures used,
the multidimensional nature of the interventions conducted and
the improvements made increase the validity of the findings
of this case series. The inclusion of rock climbing as an
intervention for individuals with ataxia adds to the body of
knowledge related to intervention for individuals with cerebellar
ataxia.
Conclusion
The individuals in this case series with moderate to severe
cerebellar ataxia due to a TBI with significant coordination,
balance and gait impairments and activity limitations met and
surpassed expectations following a physical therapy program that
was long-term, multidimensional and customized to address the
unique needs of each of the individuals. This case series reinforces
the need for long-term, multidimensional intervention for individuals with cerebellar ataxia.
Declarations of interest
The authors have no conflicts of interest to disclose regarding this report.
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